The former pharmacist was vilified and served time after Emily Jerry died. He speaks candidly about the case and how he has advocated for health care professionals since then.
After Christopher Jerry's daughter, Emily, died tragically in 2006 as the result of a preventable medical error, he became an advocate for patient safety. He also embraced the former pharmacist who committed the error, Eric Cropp.
Cropp served 6 months in prison, did 400 hours of community service, and was under house arrest, after pleading no contest to involuntary manslaughter, in exchange for a dismissal of a reckless homicide charge. Later, Christopher Jerry forgave Cropp on camera, and they then began traveling extensively together to medical conferences and facilities all over the country, giving continuing education- (CE) and continuing medical education (CME)-accredited lectures and presentations that included their distinctly different perspectives on what happened.
I caught up with Cropp, and he spoke candidly about the case and what he has been doing over the past decade.
“It’s been a roller coaster, but I’ve moved forward, and I can hopefully try to prevent other people from going through the same thing I’ve gone through,” he said.
During Cropp's house arrest, travel was nearly impossible. PharmCON contacted him about doing CE programs that were pre-recorded and he would then call in from home for the live portion. Cropp still does 3 or 4 talks each year.
He also works on different initiatives, trying to make processes safer for doctors, nurses, and pharmacists. One example is a computer program that checks these professionals' math.
Cropp is also student teaching and working on becoming a professor.
He travels and lectures, telling his story about what happened and what he has been doing to help others. Cropp has appeared before different nursing and pharmacy boards on behalf of health care professionals to ensure that errors do not lead to criminal charges. There is a higher suicide rate among providers who make errors, such as a nurse in Seattle who killed herself in 2011, 7 months after making a medication error that contributed to death of an eight-month-old baby.
Doctors, nurses, and pharmacists have higher suicide rates, because of medical mistakes and the resulting lack of support, Cropp said. He was called drunk on the job, a monster, and otherwise vilified in the media. None of it was true, but Cropp was unable to defend himself.
Some of these situations can bypass malpractice suits and go right to criminal charges. Cropp tries to help colleagues to make sure that this does not happen, saying that he did not have support after Emily Jerry died. After her death, he had flashbacks and panic attacks.
One supporter of Cropp has been Michael Cohen, RPh, MS, ScD (Hon), DPS (HON), FASHP, president of the Institute for Safe Medication Practices. Before the error occurred, Cropp had taken a pay cut to gain experience working with children. He was also very involved with the Northern Ohio Academy of Pharmacy. Cohen believed that Cropp was a decent person and did not set out to make an error.
Cohen has advocated for Cropp and for better systems to help reduce errors. He visited Cropp in jail, and knew he needed support when he got out. Cohen and his colleagues helped Cropp write lectures, keep up with developments and laws in the pharmacy industry, and generally made sure he was OK and had everything he needed. Another important factor in Cropp's emotional healing was a nurse who visited him in jail and had gone through a similar criminal proceeding and loss of license.
The ISMP wrote on its website in a medication safety alert on December 3, 2009, “When we asked Eric if there was anything in particular we could send him while he is imprisoned, he asked for newsletters and pharmacy journals to help him stay abreast of the pharmacy profession he still loves.”
Although he has Christopher Jerry’s forgiveness, Cropp still struggles with knowing that Emily’s mom, Christopher's former wife, Kelly Jerry, did not forgive him.
In Cropp’s situation, he lost his job, the technician lost her job, the nurse quit because she felt horrible about giving the IV, and the doctor ended up changing professions. If an error occurs, many times the clinician cannot handle the emotional baggage of harming someone. These errors need to be evaluated and learned from to see what caused the errors.
Becase of Cropp and Christopher Jerry speaking together and separately, many hospitals have made changes to reduce their error rates. They meet regularly and make changes as needed.
Just as Christopher Jerry has said, Cropp insists that a support system is essential. The goal after an error should not be to throw the clinician under the bus but to understand what happened and work to prevent the same error from re-occurring. Open communication, evaluation, and transparency reduces error, Cropp said.
Clinicians who have made errors often reach out to Cropp, and he makes it a point to help in any way he can, by talking to management and advocating and supporting the professional.
He was also heavily involved with petitions to eliminate time goals and metrics on filling prescriptions. Cropp faces many obstacles, especially in the retail setting, and many pharmacists are afraid to speak up for fear of losing their jobs.
But he believes he can make the biggest difference providing training to pharmacy technician training, teaching what is in the intravenous (IV) bag that they are making, what does the drug do, does the tech understand the math? Cropp realized that the tech programs did not train properly, and errors occur frequently. He also helps nursing students, with how to ask questions and not be put in situations where errors can occur.
Cropp learns from his experiences and makes lists of what works and what does not. He is working with the Community College of Cleveland to increase IV training, as techs make 96% of IVs and should receive better training.
Companies are working on tests that can check whether the IVs contain the correct medication and dosage. Cropp is excited to see this happen. He also speaks highly of a hospital whose staff meets daily and makes back-up plans for every drug shortage (the saline error in Emily Jerry’s case was due to a shortage of normal saline), and instead of blaming each other for inventory issues, the staff members make back-up plans for every shortage or situation.
Cropp is also pushing for the techs' work to be photographed, where pharmacists can consult videos to check the vials that are going into the bags.
He said that the concept of clear contents of vials going together into IV bags is terrifying, and he recalls a nearly impossible time that he had been trying to watch 7 techs. Even with 1 or 2 pharmacists, that is too many people to supervise effectively.
Cropp also has concerns that if there is a power outage, there must be a back-up way for hospitals to be able to check charts (eg, for allergies), and many are unable to do this.
He recalled personal hospital experiences where the pharmacy did not send up IVs in time, making him worry about what to do: Medication is needed, but rushing the pharmacy and putting the staff members under more stress is not a good idea. Cropp sees issues in health care not just in hospitals but in doctor's offices, emergency departments, etc., and he strives to make it a better system for everyone.
Both support and pharmacist staffing are essential. When Cropp made the error on that fateful Sunday with Emily Jerry, he had worked 16 hours Friday and 16 hours Saturday. He was supposed to be off Sunday but was called in for a double shift. There were no breaks.
Working 48 hours in 3 days is dangerous. On that Sunday, no supervisor or back-up employees showed up, so Cropp was taking care of all the patients' medication needs along with Emily Jerry’s, while being completely shaken up about the error.
In the retail pharmacy world, he advocates companies taking into account all the additional responsibilities that pharmacists have, such as administering vaccinations, answering patient questions, and talking to insurance companies in a high-pressure environment. Cropp said that many pharmacists have told him that they want to leave the profession, because the pressure of being slow enough to not make errors and yet quick enough to attain metric goals is too much for them.